General Standards of Accreditation for Institutions …...to preparing residents for independent...

General Standards of Accreditation for Institutions with Residency ProgramsVersion 1.1Last updated: July 1, 2017

© 2017 the Canadian Residency Accreditation Consortium (CanRAC), comprising the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Collège des médecins du Québec. All rights reserved.

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TABLE OF CONTENTSINTRODUCTION 3

STANDARDS ORGANIZATION FRAMEWORK 4

STANDARDS 5

DOMAIN: INSTITUTIONAL GOVERNANCE 5

STANDARD 1: 5 There is effective leadership for residency education.

STANDARD 2: 9 Residency programs are collaboratively overseen and supported by the postgraduate dean and postgraduate education committee.

STANDARD 3: 11 All learning sites contribute to resident learning and the achievement of accreditation standards for residency education.

DOMAIN: LEARNERS, TEACHERS, AND ADMINISTRATIVE PERSONNEL 12

STANDARD 4: 12 Safety and wellness is promoted throughout the learning environment.

STANDARD 5: 14 Residents are treated fairly and adequately supported throughout their progression through their residency program.

STANDARD 6: 16 Teachers are valued and supported in the delivery of residency programs.

STANDARD 7: 17 Administrative personnel are valued and supported in the delivery of residency programs.

DOMAIN: CONTINUOUS IMPROVEMENT 18

STANDARD 8: 18 There is continuous improvement of the postgraduate structure and governance, and of residency programs.

STANDARD 9: 21 There is continuous improvement of the learning sites to improve the educational experience, ensuring the learning environment is appropriate, safe and conducive to preparing residents for independent practice.

GLOSSARY OF TERMS 22

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INTRODUCTIONThe General Standards of Accreditation for Institutions with Residency Programs are a national set of standards maintained conjointly by the Royal College, College of Family Physicians of Canada (CFPC) and Collège des médecins du Québec (CMQ) for the evaluation and accreditation of institutions with residency programs. The aim of the standards is to ensure residency programs are supported to adequately prepare residents to meet the health care needs of the population(s) they serve, upon completion of training.

The standards include requirements applicable to faculties of medicine, postgraduate offices, and learning sites1, and have been written in alignment with a standards organization framework which aims to provide clarity of expectations, while maintaining flexibility for innovation.

1 Note: The General Standards of Accreditation for Institutions with Residency Programs also include standards applicable to learning sites.

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STANDARDS ORGANIZATION FRAMEWORKLevel Description

Domain Domains were defined by the Future of Medical Education in Canada-Postgraduate (FMEC-PG) Accreditation Implementation Committee to introduce common organizational terminology, to increase alignment of accreditation standards across the medical education continuum.

Standard The overarching outcome to be achieved through the fulfillment of the associated requirements.

Element A category of the requirements associated with the overarching standard.

Requirement A measurable component of a standard.

Mandatory & Exemplary Indicators

A specific expectation used to evaluate compliance with a requirement (i.e. to demonstrate that the requirement is in place).

Mandatory indicators must be met to achieve full compliance with a requirement. Exemplary indicators provide improvement objectives beyond the mandatory expectations and may be used to introduce indicators that will become mandatory over time.

Indicators may have one or more sources of evidence, not all of which will be collected through the onsite accreditation visit (e.g. external data, documentation within the institution/program portfolio, etc.).

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STANDARDSDOMAIN: INSTITUTIONAL GOVERNANCE

The Institutional Governance domain focuses on the overall oversight and governance of residency programs. The institutional governance standards aim to:

u Ensure the Faculty of Medicine provides effective leadership for residency education;

u Outline the high-level responsibilities of the postgraduate dean and the postgraduate education committee(s); and

u Outline the relationships with, and oversight of, all learning sites used for residency education.

STANDARD 1: There is effective leadership for residency education.

Element 1.1: There is a vision/mission for residency education.

Requirement(s) Indicator(s)

1.1.1: There is a vision/mission identifying the Faculty of Medicine’s overarching purpose in residency education.

1.1.1.1: The vision/mission articulates the Faculty of Medicine’s role in residency education and other parts of the continuum of medical education, within its relationship with the University.

1.1.1.2: The vision/mission explicitly addresses the Faculty of Medicine’s role in ensuring its residency programs address the societal health needs of the population(s) they serve.

1.1.1.3: The vision/mission is shared with all residency education stakeholders.

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Element 1.2: There is effective senior leadership to oversee residency education.


1.2.1: There is a postgraduate dean with authority and responsibility for all aspects of residency education.

1.2.1.1: The postgraduate dean is accountable to the dean of the Faculty of Medicine.

1.2.1.2: The postgraduate dean is responsible for overseeing residency education as outlined in the standards for accreditation.

1.2.1.3: There is a job description for the postgraduate dean, which outlines the mandate, expectations, protected time, supports, resources, reporting and accountability for his/her role in oversight of residency programs.

1.2.1.4: There is an effective process to conduct a regular and formal review of the postgraduate dean’s performance, which includes multiple sources of feedback.

1.2.2: The postgraduate dean provides effective leadership for residency education.

1.2.2.1: The postgraduate dean fosters an environment which empowers members of the postgraduate education committee(s), program directors, residents, teachers, and others, as required, to identify needs and implement changes.

1.2.2.2: The postgraduate dean advocates for equitable and appropriate resources to allow delivery of effective educational experiences.

1.2.2.3: The postgraduate dean advocates, fosters, and nurtures collaborative relationships with residency education stakeholders.

1.2.2.4: The postgraduate dean effectively anticipates and manages conflict.

1.2.2.5: The postgraduate dean respects the diversity and protects the rights and confidentiality of residents, teachers, and program directors.

1.2.2.6: The postgraduate dean demonstrates active professional engagement in medical education.

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1.2.2.7: The postgraduate dean demonstrates effective leadership in collaborating with other partners (e.g. learning sites) in the delivery of clinical care.

1.2.2.8: [Exemplary]: The postgraduate dean demonstrates commitment to and/or facilitates educational scholarship and innovation to advance residency education.

1.2.3: The postgraduate dean has appropriate time and support to oversee residency education.

1.2.3.1: The postgraduate dean is supported by the Faculty of Medicine to effectively oversee residency education.

1.2.3.2: The postgraduate dean has adequate protected time.

1.2.3.3: The postgraduate dean has appropriate postgraduate administrative personnel support.

1.2.3.4: The postgraduate dean and postgraduate administrative personnel have access to adequate space and information technology to effectively oversee residency education.

1.2.4: The postgraduate dean is involved in the appointment and continuous professional development of each program director.

1.2.4.1: There is a standardized job description for program directors, which outlines the mandate, expectations, supports, resources, protected time, reporting and accountability for the role.

1.2.4.2: There is a collaborative process between the academic lead of the discipline and the postgraduate dean for the appointment of each program director.

1.2.4.3: Each program director meets the required credentials as set by the college(s) and the standards of accreditation for the discipline, as appropriate.

1.2.4.4: The postgraduate dean is involved in the orientation, mentorship and continuous professional development of program directors.

1.2.4.5: There is an effective process using multiple sources of feedback, for regular and formal review of each program director’s performance, conducted collaboratively between the academic lead of the discipline and the postgraduate office.

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Element 1.3: There is an effective postgraduate education committee structure, overseen by the postgraduate dean, to facilitate the governance and oversight of all residency programs.


1.3.1: The postgraduate education committee structure is composed of appropriate residency education stakeholders.

1.3.1.1: The postgraduate education committee(s) is (are) a forum for input from all residency programs.

1.3.1.2: There is functional and effective representation from residents, program directors, learning sites, and postgraduate administrative personnel on the postgraduate education committee(s).

1.3.1.3 [Exemplary]: There is functional and effective representation from the public on the postgraduate education committee.

1.3.2: The postgraduate education committee fulfils its responsibilities regarding residency education.

1.3.2.1: The postgraduate education committee has clearly written terms of reference that are reviewed regularly, and address its composition, mandate, roles and responsibilities, and meeting process.

1.3.2.2: The postgraduate education committee is accountable for supporting the postgraduate dean in planning, organizing and evaluating all aspects of residency education.

1.3.2.3 The meeting frequency of the postgraduate education committee is sufficient for the committee to fulfill all aspects of its mandate.

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STANDARD 2: Residency programs are collaboratively overseen and supported by the postgraduate dean and postgraduate education committee.Element 2.1: Element 2.1: There are effective policies governing residency education.


2.1.1: The postgraduate education committee has well-defined, transparent, and functional policies and processes to oversee residency education.

2.1.1.1: The process of policy development, adoption, and dissemination is transparent, effective, and collaborative.

2.1.1.2: Residents, teachers and administrative personnel have access to the policies.

2.1.1.3: The postgraduate education committee(s)’s policies and processes address all aspects of residency education, as outlined in the standards of accreditation.

2.1.1.4: The postgraduate dean and postgraduate education committee regularly review and make necessary changes to their policies.

Element 2.2: The postgraduate dean and the postgraduate education committee advocate for the resources and support needed for the functioning of quality residency programs.


2.2.1: The postgraduate dean and postgraduate education committee facilitate residency programs in meeting the specific standards for the discipline and achieve the Faculty of Medicine vision/mission, including its social accountability mandate.

2.2.1.1: The postgraduate dean and postgraduate education committee support programs in integrating the vision/mission in the context of the discipline.

2.2.1.2: The postgraduate dean and postgraduate education committee support residency programs in meeting the specific standards for the discipline.

2.2.1.3: The postgraduate dean and postgraduate education committee identify social accountability as a priority and help build capacity within individual residency programs to meet the needs of the population(s) served.

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2.2.2: There are adequate resources and support to allow residency programs to meet accreditation standards.

2.2.2.1: There is an effective process to identify resource needs and advocate for equitable allocation of resources for each residency program.

2.2.2.2: There are written guidelines to ensure support for the program director, including administrative support and remuneration, which provide flexibility to accommodate the variation in the size and complexity of residency programs.

2.2.2.3: Residency programs have access to legal services, as appropriate.

2.2.2.4: Residency programs have access to technology, such as videoconferencing and simulation facilities, and associated support staff.

2.2.2.5: Residency programs have access to centralized support for scholarly activities, including research, as appropriate.

2.2.3: A confidential system of resident and teacher information management is maintained.

2.2.3.1: There is an effective centralized policy for information management that addresses access, confidentiality and information retention.

2.2.3.2: There are up-to-date and confidential files for all residents and teachers, with procedures and practices to safeguard privacy and confidentiality.

Element 2.3: The postgraduate dean and postgraduate education committee communicate and collaborate with residency education stakeholders.


2.3.1: The postgraduate dean and postgraduate education committee maintain effective working relationships with all residency education stakeholders.

2.3.1.1: There is timely and effective communication with the program director, residency program committee(s), and administrative personnel.

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2.3.1.2: There is effective communication and collaboration with the undergraduate, continuous professional development and faculty development offices to promote optimal delivery of residency programs and effective transition along the educational continuum.

2.3.1.3: There is effective communication and collaboration with learning sites, other health professionals, and government, as appropriate, regarding the design and improvement of residency education.

2.3.1.4: There is effective communication with the certifying colleges and the medical regulatory authority(ies), as appropriate.

STANDARD 3: All learning sites contribute to resident learning and the achievement of accreditation standards for residency education.Element 3.1: Formal relationships are established with all learning sites that contribute to residency education.


3.1.1: Each learning site’s role in delivering residency education is clearly articulated.

3.1.1.1: Effective, formal relationships, including affiliation agreements, as appropriate, are in place with all learning sites that contribute to and actively support residency education.

3.1.1.2: Formal relationships with all learning sites are regularly reviewed.

3.1.1.3: The postgraduate dean and postgraduate education committee provide support for and facilitate the review of learning sites.

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DOMAIN: LEARNERS, TEACHERS, AND ADMINISTRATIVE PERSONNEL

The Learners, Teachers, and Administrative Personnel domain includes standards focused on supporting residents, teachers, and administrative personnel – “people services and supports”. The institution-level Learners, Teachers, and Administrative Personnel domain standards aim to ensure:

u A safe and positive learning environment;

u Recognition of the value of and provision of support for teachers and administrative personnel; and

u Fair treatment and support for residents throughout progression through the residency program.

STANDARD 4: Safety and wellness is promoted throughout the learning environment. Element 4.1: The safety and wellness of patients and residents are actively promoted.


4.1.1: Residents are appropriately supervised.

4.1.1.1: There are effective centralized policies and guidelines regarding supervision, that consider discipline- and program-specific contexts, and allow for program-specific additions and/or variations, as appropriate.

4.1.1.2: Programs are supported to identify and remediate inadequate supervision.

4.1.1.3: Teachers, residents and learning site staff (e.g. site coordinators, site directors) are aware of the process to report concerns regarding resident supervision.

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4.1.2: Patient safety is promoted throughout residency programs and learning sites.

4.1.2.1: The review of safety policies and guidelines is informed by data relating to adverse events involving residents and all individuals involved in resident teaching.

4.1.2.2: Residency programs are provided with resources and expertise to facilitate the incorporation of patient safety in residency programs.

4.1.2.3: Reporting of resident performance and/or status to the medical regulatory authority when such reporting is required is systematic, timely, and transparent.

4.1.2.4: The postgraduate office provides residents with timely educational accommodation, leaves of absence, and withdrawal processes, as appropriate, and when deemed necessary (e.g., for patient safety).

4.1.2.5 [Exemplary]: The postgraduate office has a designated individual focused on quality of care and patient safety, providing support to residency programs

4.1.3: Residency education occurs in a safe learning environment.

4.1.3.1: Safety is actively promoted throughout the learning environment for all involved in residency education.

4.1.3.2: There are is an (are) effective centralized policy(ies) addressing residents’ physical, psychological, and professional safety, including but not limited to: travel,

i. patient encounters (including house calls),

ii. after-hours consultation,

iii. patient transfers (e.g., Medevac),

iv. fatigue risk management, and

v. complaint management.

4.1.3.3: Centralized policies and guidelines regarding resident safety consider discipline- and program-specific contexts and allow for program-specific additions and/or variations, as appropriate.

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4.1.3.4: Concerns with the safety of the learning environment are appropriately identified and appropriately remediated.

4.1.3.5: There is an effective plan for management of resident involvement in extraordinary circumstances (e.g., mass casualty events and epidemics).

4.1.3.6 [Exemplary]: There are centralized resources available for residency programs and residents to help support, develop, and implement Fatigue Risk Management Plans (FRMP).

4.1.4: Residency education occurs in a positive learning environment that promotes resident wellness

4.1.4.1: There is a positive learning environment for all involved in residency education.

4.1.4.2: There is an (are) effective centralized policy (ies) addressing residents’ wellness, including but not limited to absences and educational accommodation.

4.1.4.3: Centralized policies and guidelines regarding resident wellness consider discipline- and program-specific contexts and allow for program-specific additions and/or variations, as appropriate.

4.1.4.4: The postgraduate office has an effective mechanism for reporting and addressing instances of mistreatment.

4.1.3.5: Residents have access to a designated, confidential, support resource/service to whom/which residents experiencing wellness difficulties, including stress and illness, can access.

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STANDARD 5: Residents are treated fairly and adequately supported throughout their progression through their residency program. Element 5.1: All residents are treated fairly and supported in their academic progression.


5.1.1: There is fair and transparent oversight of the academic progression of residents.

5.1.1.1: The centralized policies and processes that address resident selection, assessment, formal remediation, and appeals, are regularly reviewed, transparent, and effectively applied.

5.1.1.2: Residents and teachers are involved in the development, approval, and implementation of formal remediation programs.

5.1.2: Support services are available to facilitate resident achievement and success.

5.1.2.1: Residents have access to confidential career counseling services.

5.1.3: Resident leadership is encouraged and promoted.

5.1.3.1: Residents are encouraged and provided with appropriate support to participate in positions of leadership.

5.1.3.2: There are fair and transparent processes to select residents for leadership positions.

STANDARD 6: Teachers are valued and supported in the delivery of residency programs. Element 6.1: Teachers are fairly assessed and supported in their development and career progression.


6.1.1: There is a process of systematic teacher assessment and feedback.

6.1.1.1: There is an effective process for the assessment of teachers involved in residency education.

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6.1.1.2: The process for the assessment of teachers includes resident input, balancing timely feedback with preserving resident confidentiality.

6.1.1.3: The process for the assessment of teachers informs teacher recognition, continuous improvement of residency programs, and the assignment of residents to teachers.

6.1.1.4: Concerns with teacher behavior or performance are addressed in a fair and timely manner.

6.1.1.5: Reporting of teacher performance and/or status to the medical regulatory authority, when such reporting is required, is systematic, timely, and appropriate.

6.1.1.6: Teachers and residents are aware of the process to report concerning behavior by teachers.

6.1.1.7: Teachers are aware of and have access to an appeal process for decisions related to their assessments.

6.1.2: Teachers engage in and are supported in their development and career progression.

6.1.2.1: There is an effective policy for the appointment and promotion of teachers.

6.1.2.2: There is a dedicated, accessible faculty development program.

6.1.2.3: Faculty development programming is based on the identification of learning needs.

6.1.2.4: Faculty development is effectively used to support implementation of educational innovations.

6.1.2.5 [Exemplary]: Teachers have protected time to access the resources to support their development and career progression.

6.1.2.6 [Exemplary]: Teachers have access to appropriate resources to obtain advice with respect to teaching.

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6.1.3: Teachers are supported in their responsibility to serve as role models for residents.

6.1.3.1: Teachers are supported and recognized for their contributions to scholarship.

6.1.3.2: Teachers are supported and recognized for their contributions to academic activities within his/her residency program and the institution, which may include, but are not limited to: lectures, workshops, examination preparation, and internal reviews.

6.1.3.3: Teachers are supported and recognized for their contributions outside of the program, which may include, but are not limited to: peer reviews, medical licensing authorities, exam boards, specialty committees, accreditation committees, and government medical advisory boards.

STANDARD 7: Administrative personnel are valued and supported in the delivery of residency programs.Element 7.1: There is support for the selection and continuing professional development of administrative personnel involved in the administration of residency education.


7.1.1: There is an effective process for the selection of and professional development for administrative personnel involved in residency education.

7.1.1.1: There is a standardized job description for postgraduate and residency program administrative personnel involved in residency education, which outlines the mandate, expectations, time allocation, reporting and accountability for the role.

7.1.1.2: There are criteria and guidelines for the selection and recognition of administrative personnel.

7.1.1.3: There is a program of professional development for administrative personnel involved in residency education based on identification of their learning needs.

7.1.1.4: There is a fair and transparent process for administrative personnel performance management.

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DOMAIN: CONTINUOUS IMPROVEMENT

The Continuous Improvement domain includes standards focused on ensuring a culture of continuous improvement is present throughout the Faculty of Medicine, the postgraduate office, residency programs, and learning sites. The institution-level continuous improvement domain standards aim to ensure:

u Continuous improvement of the postgraduate office structure and governance;

u Support for and oversight of continuous improvement of residency programs; and

u The active engagement of learning sites in the continuous improvement of the learning environment.

Note: To reinforce and create clarity with respect to the expectations related to continuous improvement, the Requirements under each Element mimic the continuous improvement cycle (Plan, Do, Study, Act).

STANDARD 8: There is continuous improvement of the postgraduate structure and governance, and of residency programs.Element 8.1: The postgraduate dean and postgraduate education committee(s) continuously review and improve the quality of the postgraduate structure and governance.


8.1.1: There is a process to review and improve the postgraduate structure and governance.

8.1.1.1: There is an evaluation of the postgraduate structure and governance.

8.1.1.2: There are assessments of the performance of leadership and postgraduate administrative personnel.

8.1.2: A range of data and information is reviewed to inform evaluation and improvement of the postgraduate structure and governance.

8.1.2.1: Multiple sources of feedback are regularly reviewed, including feedback from residents, teachers, administrative personnel and program directors, as appropriate.

8.1.2.2: Mechanisms for feedback take place in an open, collegial atmosphere.

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8.1.3: Based on the data and information reviewed, strengths are identified and action is taken to address areas identified for improvement.

8.1.3.1: Areas for improvement are used to identify and implement relevant and timely action plans.

8.1.3.2: The postgraduate dean and postgraduate education committee share their identified strengths and action plans with relevant residency education stakeholders in a timely manner.

8.1.3.3: There is a clear and well-documented process to review the effectiveness of actions taken, and to take further action as required.

Element 8.2: The postgraduate dean and postgraduate education committee continuously identify, monitor, and address issues affecting residency program quality.


8.2.1: There is a process to internally review and improve residency programs.

8.2.1.1: An internal review process is conducted for each residency program, at least once per regular accreditation cycle.

8.2.1.2: The internal review process evaluates how well each residency program is meeting all standards of accreditation, including both the general standards of accreditation for the residency program and the specific standards of accreditation for the discipline.

8.2.1.3: The internal review process includes effective mechanisms to follow through on areas for improvement identified for residency programs, and ensures actions are taken for improvement.

8.2.1.4: The internal review process identifies common areas for improvement across residency programs.

8.2.1.5: The internal review process reviews how well residency programs are preparing residents for independent practice.

8.2.1.6: The internal review process includes reflection on the potential impacts of the hidden curriculum on the learning experience.

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8.2.2: A range of data and information is reviewed to evaluate and improve learning sites and residency programs.

8.2.2.1: Multiple sources of information, including feedback from residents, teachers, administrative personnel and program directors, as appropriate, are regularly reviewed.


8.2.3: Based on the data and information reviewed, Faculty of Medicine-wide and/or learning site-specific strengths are identified and action is taken to address areas identified for improvement.

8.2.3.1: Areas for improvement are used to develop and implement relevant and timely action plans for issues that are Faculty of Medicine-wide and/or learning site-specific.

8.2.3.2: The postgraduate dean and postgraduate education committee share identified strengths and action plans with residency program and learning site leadership, and other residency education stakeholders as appropriate, in a timely manner.

8.2.3.3: There is a clear and well-documented process to evaluate the effectiveness of actions taken, and to take further action as required.

Element 8.3: The postgraduate dean and postgraduate education committee build capacity and facilitate residency programs to identify, monitor and correct issues through continuous improvement.


8.3.1: The postgraduate dean and postgraduate education committee support the program evaluation and continuous improvement processes of residency programs.

8.3.1.1: The postgraduate dean and postgraduate education committee facilitate residency programs’ access to data and reports prepared for the purposes of supporting continuous improvement processes.

8.3.1.2: There is support provided by the postgraduate dean and postgraduate education committee to assist residency programs identified as having issues in addressing areas identified for improvement.

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STANDARD 9: There is continuous improvement of the learning sites to improve the educational experience, ensuring the learning environment is appropriate, safe and conducive to preparing residents for independent practice.

Element 9.1: There is a collaborative process to review and improve the quality of the learning environment.


9.1.1: There is a process to regularly review and improve the learning environment in each learning site.

9.1.1.1: There is a process to regularly review the learning environment at each learning site with respect to the delivery of the clinical components of the residency program, including the quality of clinical care and resources as it relates to residents’ achievement of competencies.

9.1.1.2: Learning sites with a formal affiliation agreement with the Faculty of Medicine are accredited in good standing by Accreditation Canada (or equivalent).

9.1.1.3: Learning sites regularly review the safety of the learning environment for patients.

9.1.1.4: Learning sites regularly review the safety (physical, psychological, and professional, as appropriate) of the learning environment for residents.

9.1.2: A range of data and information is reviewed to inform evaluation and improvement of the quality of the learning environment at each learning site.

9.1.2.1: Multiple sources of information, including feedback from residents, teachers, administrative personnel, and program directors, as appropriate, are regularly reviewed.

9.1.2.2: There is an effective process for the learning site to access and review information/data identified by the postgraduate office’s internal review process, and any data centrally collected by the postgraduate office and residency program, as appropriate.


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9.1.2.4 [Exemplary]: The process includes regular review of clinical outcomes (e.g. public health data) and patient feedback data.

9.1.3: Based on the data and information reviewed, strengths are identified, and action is taken to address areas identified for improvement.

9.1.3.1: Areas for improvement are used to develop and implement relevant and timely action plans to improve the quality of the learning environment.

9.1.3.2: The learning site-specific strengths and action plans are shared with appropriate postgraduate and residency program leadership in a timely manner.

9.1.3.3: There is a clear and well-documented process to review the effectiveness of actions taken, and to take further action as required.

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GLOSSARY OF TERMS

Term Description

Academic lead of the discipline

The individual responsible for a clinical department/division (e.g. department chair, division lead, etc.)

Administrative personnel

Postgraduate and program administrative personnel, as defined below.

Affiliation agreement

A legal contract that defines the roles and responsibilities of a learning site and institution in delivering residency education.

Assessment A process of gathering and analyzing information on competencies from multiple and diverse sources in order to measure a physician’s competence or performance and compare it to defined criteria.2

Attestation Verification of satisfactory completion of all necessary training, assessment and credentialing requirements of an area of medical expertise. Attestation does not confer certification in a discipline.3

Centralized This term applies to policies, processes, guidelines and/or services developed by the University, Faculty of Medicine, postgraduate office, and/or postgraduate education committee, and applied to more than one residency program.

2 The Royal College of Physicians and Surgeons of Canada (2012). Terminology in Medical Education Project: Draft Glossary of Terms. Retrieved October 14, 2016 from http://www.royalcollege.ca/rcsite/education-strategy-accreditation/innovations-development/initiatives/terminology-medical-education-project-e


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Certification Formal recognition of satisfactory completion of all necessary training, assessment and credentialing requirements of a discipline, indicating competence to practice independently.4

CFPC College of Family Physicians of Canada.

CMQ Collège des médecins du Québec

Competence The array of abilities across multiple domains of competence or aspects of physician performance in a certain context. Statements about competence require descriptive qualifiers to define the relevant abilities, context and stage of training or practice. Competence is multi-dimensional and dynamic; it changes with time, experience, and settings.5

Competency (Competencies)

An observable ability of a health professional related to a specific activity that integrates knowledge, skills, values, and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition. Competencies can be assembled like building blocks to facilitate progressive development.6

Competent Possessing the required abilities in all domains of competence in a certain context at a defined stage of medical education or practice.7

Continuing Professional Development

An ongoing process of engaging in learning and development beyond initial training, which includes tracking and documenting the acquisition of skills, knowledge and experiences.

4 The Royal College of Physicians and Surgeons of Canada (2012). Terminology in Medical Education Project: Draft Glossary of Terms. Retrieved October 14, 2016 from http://www.royalcollege.ca/rcsite/education-strategy-accreditationnnovations-development/initiatives/terminology-medical-education-project-e

5 Frank, JR., Snell, L., Ten Cate, O., Holmboe, ES., Carraccio, C., Swing, SR., et al. (2010). Competency-based medical education: theory to practice. Medical Teacher; 32(8):638-645.



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Continuous Improvement

The systematic approach to making changes involving cycles of change (i.e. Plan, Do, Study, Act) that lead to improved quality and outcomes. It is used as an internal tool for monitoring and decision-making, (e.g., what are the strengths and weaknesses of the residency program? How can we improve our system of assessment?)

Dean The senior faculty officer appointed to be responsible for the overall oversight of a Faculty of Medicine.

Discipline Specialty and/or subspecialty recognized by one of the certification colleges.8

Division/Department

An organizational unit around which clinical and academic services are arranged.

Domain(s) of competence

Broad distinguishable areas of competence that together constitute a general descriptive framework for a profession(s).9

Educational Accommodation

Recognizing that people have different needs and taking reasonable efforts to ensure equal access to residency education.

Evaluation A process of employing a set of procedures and tools to provide useful information about medical education programs and their components to decision-makers (RIME Handbook). This term is often used interchangeably with Assessment when applied to individual physicians, but is not the preferred term.10

Equitable Used in the context of having and/or allocating resources, and refers to fair and impartial distribution of resources.11

8 Association of American Medical Colleges (2012). Draft Glossary of Competency-Based Education Terms (unpublished).

9 Association of American Medical Colleges (2012). Draft Glossary of Competency-Based Education Terms (unpublished).


11 Oxford University Press. (2016) Oxford Living Dictionary: Equitable. Retrieved October 14, 2016 from https//en.oxforddictionaries.com/definition/equitable

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Faculty Development

That broad range of activities institutions use to renew or assist teachers in their roles.12

Faculty of Medicine

A Faculty of Medicine, School of Medicine, or College of Medicine under the direction of a Canadian university/universities.

Fatigue Risk Management

A set of ongoing fatigue prevention practices, beliefs, and procedures integrated throughout all levels of an organization to monitor, assess, and minimize the effects of fatigue and associated risks for the health and safety of healthcare personnel and the patient population they serve. [This is a working definition only, and is under further development]

Hidden curriculum A set of influences that function at the level of organizational structure and culture, affecting the nature of learning, professional interactions, and clinical practice [As defined in the FMEC MD Education Project Collective Vision]

Independent practice

Practice in which physicians are licensed to be accountable for their own medical practice that is within their scope of practice and that normally takes place without direct supervision.

Institution Encompasses the University, Faculty of Medicine, and postgraduate office.

Inter-institutional Agreement (IIA)

A formal agreement used in circumstances where a Faculty of Medicine requires residents to complete a portion of their training under another recognized Faculty of Medicine, in alignment with policies and procedures for IIAs as set by the Royal College, CFPC, and/or CMQ.

Internal review An internal evaluation conducted to identify strengths of, and areas for, improvement for the residency program and/or Faculty of Medicine.

Inter-professional Individuals from two or more professions (i.e., medicine and nursing) working collaboratively with shared objectives, decision-making, responsibility and power, to develop care plans and make decisions about patient care (CanMEDS).

12 Great Schools Partnership (2012). The Glossary of Education Reform. Retrieved October 14, 2016 from http://edglossary.org/learning-environment

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Intra-professional Two or more individuals from within the same profession (i.e. medicine), working together interdependently to develop care plans and make decisions about patient care (CanMEDS).

Learning environment

The diverse physical locations, contexts, and cultures in which residents learn.12

Learning site A hospital, clinic or other facility which contributes to residents’ educational experiences.13

Medical Regulatory Authority

An organization established by provincial or territorial legislation to regulate the practice of medicine and licensure.

Mistreatment Unprofessional behavior involving intimidation, harassment, and/or abuse.

Objective(s) An outcomes-based statement that describes what the resident will be able to do upon completion of the learning experience, stage of training, or residency program.

Postgraduate administrative personnel

Individuals who support the postgraduate dean in coordination and administration related to the oversight of residency programs, including the postgraduate manager.

Postgraduate dean

A senior faculty officer appointed to be responsible for the overall conduct and supervision of postgraduate medical education within the Faculty of Medicine.

Postgraduate education committee

The committee and any subcommittees as applicable, overseen by the postgraduate dean, which facilitates the governance and oversight of all residency programs within a Faculty of Medicine.

Postgraduate manager

Senior administrative personnel responsible for supporting the postgraduate dean, providing overall administrative oversight of the postgraduate office.

Postgraduate office

A postgraduate medical education office under the direction of the Faculty of Medicine, with responsibilities for residency programs.

13 Great Schools Partnership (2012). The Glossary of Education Reform. Retrieved October 14, 2016 from http://edglossary.org/learning-environment/

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Program administrative personnel

Individuals who support the program director by performing administrative duties related to planning, directing, and coordinating the residency program.

Program director The individual responsible and accountable for the overall conduct and organization of the residency program. The individual is accountable to the postgraduate dean and academic lead of the discipline.

Protected time A designated period of time granted to an individual for the purposes of performing a task and/or participating in an activity.

Residency program

An accredited residency education program in one of Canada’s nationally recognized disciplines, associated with a recognized Faculty of Medicine, overseen by a program director and residency program committee.

Residency program committee(s)

The committee and subcommittees, as applicable, overseen by the program director that supports the program director in the administration and coordination of the residency program.

Residency program stakeholder

A person or organization with interest in and/or who is impacted by the residency program.

Resident An individual registered in an accredited residency program following eligible undergraduate training leading to certification or attestation in a recognized discipline.14

Resource Include educational, clinical, physical, technical, financial, and human (e.g. teachers and administrative personnel) resources required for delivery of a residency program.

Royal College The Royal College of Physicians and Surgeons of Canada.

Site coordinator The coordinator/supervisor with responsibility for residents at a learning site.


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Social Accountability

The direction of education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation. Priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.15

Teacher An individual with the responsibility for teaching residents. Teacher is often used interchangeably with terms such as supervisor and/or preceptor.

Teaching Includes formal and informal teaching of residents, including the hidden curriculum.

Wellness A state of health, namely, a state of physical, mental, and social well-being, that goes beyond the absence of disease or infirmity.16

15 Boelen C., Heck J. (1995). Defining and measuring the social accountability of medical schools. World Health Organization. Geneva, Switzerland.

16 World Health Organization (1948). WHO definition of health. Retrieved October 14, 2016 from http://www.who.int/about/definition/en/print.html

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